Introduction to the Physical Examination

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Introduction to the Physical Examination
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Todays Agenda

• Overview of course
• Exam techniques and use of equipment
• Vital signs

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Introduction to the Medical Profession

• Not an introduction, but a beginning
• A new type of learning experience
• The study of the patient
• The study of illness as opposed to disease

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IMP is a two year course

• IMP I
• Primary Care Externship
• Communication and Interviewing
• Physical Examination
• Clinical Decision Making - EBM

• IMP II
• Adv. Communication and Interviewing
• Physical Diagnosis
• Radiology, Laboratory and problem-solving
• Clinical Decision Making-EBM

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Student Goals

• To understand the underlying anatomy and
  physiology of the normal physical examination
• To be able to perform a complete screening
  physical examination in a logical fashion with
  minimal discomfort to the patient.
• To be able to recognize normal findings on the
  physical examination

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Expectations

• Attendance
• Participation
• Professionalism
• Honesty
• Feedback
• Attitude

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Physical Examination

• Lecture series
• Small group session
• CSTAC

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Assessment

• Multiple choice examination
• Practical examination
• History
• Physical examination

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Basic Clinical Skills

• 70 of diagnosis can be based on history alone
• 90 of diagnosis can be made when the physical
  examination is added
• Expensive tests often confirm what is found in
  the HP

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• The major effort in becoming a diagnostician
  consists in acquiring the intellectual background
  to make his or her perceptions meaningful - in
  short, he or she must practice and study.
• DeGowin and DeGowin

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Physical ExaminationTwo Tiers of Investigation

• Screening or Comprehensive Examination
• The foundation of clinical skills
• Uses
• Undifferentiated patient
• New patient
• Pt wishing a complete HP

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Physical ExaminationTwo Tiers of Investigation

• Extended or Problem-Focussed Examination
• Physician follows leads
• Usually involves an extended assessment of a
  system or region

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Physical Examination

• Knowledge Base
• Technical Skills
• Exam skills
• Use of equipment

• Perceptual Skills
• Sensory
• Interpretation
• Communication Skills
• Interpersonal Skills

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Knowledgebase

• Normal examination
• Anatomy
• Physiology
• Techniques
• Equipment
• Expected normal findings
• Normal variations
• Changes with age
• Extrapolation to common abnormalities

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Learning the Physical Examination

• A key to a thorough and accurate physical
  examination is developing a systematic sequence
  of examination

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Learning the Physical Examination

• An important goal is to minimize the number of
  times you ask the patient to change positions

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Learning The Physical Examination

• Systems Approach ? Regional Approach
• Small group sessions with preceptor
• Lecture series
• Reading Bates
• Practice
• Review session with SPs

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Format of Small Group Sessions

• Read material ahead of time
• Use objectives as a guide
• Do the practice questions and review with
  preceptor
• Practice exam techniques
• Use checklist as a guideline

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The Syllabus
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Lecture Schedule
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Small Group Sessions
1.Getting started 2. HEENT, neck, lymph nodes 3.
Cardiovascular, peripheral vascular 4. Chest,
pulmonary 5 Abdomen 6 Neurological 7.
Musculoskeletal 8.9.Putting it all
together 10.Patients
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Practice Questions
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Checklist
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Checklist Explained
Systolic blood pressure should be estimated the
first time a patient's blood pressure is taken.
This is done by palpating the brachial or radial
arteries after the pulse is palpated, slowly
inflate the blood pressure cuff and note the
blood pressure at which the pulse is no longer
palpable.
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Learning Resources

• Required Textbook Bates. . A Guide
• to Physical Exam and History Taking. 9th ed.
• Philadelphia Lippincott, 2005

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Examination Techniques and Equipment
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Examination Techniques and Equipment

• Objectives for each section
• General Appearance
• Appreciate the importance of observation
• Exam techniques
• Inspection
• List what some examples of what to look for in
  general observation
• List a few conditions that are diagnosed from
  general inspection
• The type of lighting is best for observing
  couture
• Percussion
• Definition of percussion
• Types of percussion
• Uses of percussion
• The technique of percussion
• Be able to perform direct and indirect percussion
• The percussion notes and what they indicate
• Recognize percussion notes
• Be able to interpret physical exam findings based
  on percussion

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Examination Techniques

• Inspection
• Percussion
• Palpation
• Auscultation

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Observation (Inspection)

• Least mechanical part of the physical examination
• Hardest to learn
• Yields the most physical signs
• More diagnoses are made by inspection than all
  others combined
• Depends upon the knowledge of the observer

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How to Observe

• Keep your eyes open
• Keep an open mind
• Ask questions
• Learn what to observe
• Reflect on what you have observed and look for
  what you may have missed

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• Finished files are the re-
• sult of years of scientif-
• ic study combined with
• the experience of years.

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Observation

• Never mind, said Holmes, laughing it is my
  business to know things. Perhaps I have trained
  myself to see what others overlook. If not, why
  should you come to consult me?
• A case of Identity from Adventures of Sherlock
  Holmes

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The precise and intelligent recognition and
appreciation of minor differences is the real
essential factor in all successful medical
diagnosis- Joseph Bell, MD (1890)

• The character of Sherlock Holmes was based on Dr.
  Bell, an English surgeon who taught Arthur Conan
  Doyle during medical school.

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Enhancing Your Powers of Observation

• Learning physical examination techniques is all
  about becoming a better observer
• A skilled clinician has enhanced powers of
  observation and the knowledge to use these
  observations in the care of patients

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Dont touch the patient - state first what you
see cultivate your powers of observation.Sir
William Osler
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The student must teach the eye to see, the
fingers to feel, and the ear to hear.Sir
William Osler
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Observation

• What you see
• Know what to look for
• What you hear (listening)
• Olfactory diagnosis
• What you feel emotionally

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Observation Inspection

• Least mechanical aspect of the physical
  examination
• Hardest to learn
• Yields the most physical signs
• More diagnosis are made by inspection than all
  other techniques combined
• Depends upon the knowledge of the observer

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Inspection

• Begins when you first see the patient and ends
  when they leave
• Systematic part of each component of the physical
  examination
• Part of the mental status examination
• Subtle observations probably account for the
  sixth sense of astute clinicians

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Inspection General Appearance

• State of consciousness
• Signs of distress (sick or not sick?)
• Apparent state of health
• Skindiscoloration or obvious lesions
• Dress, grooming, and personal hygiene
• Facial expression
• Gait and posture
• Motor activity

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Dress, grooming, and personal hygiene
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Inspection General Appearance

• State of nutrition
• Body habitus
• Symmetry
• Stated age vs. physiologic age
• Mood, attitude, affect
• Speech
• Olfactory diagnosis
• Bodily excretions (Effuvia)

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Olfactory Diagnosis

• Medical olfaction can often be an important
  aspect
• of clinical examination if clinicians approach
  patient
• encounters with an open nose as well as an open
• mind.
• Hayden, GF Olfactory diagnosis in medicine, Post
  Graduate Medicine,
• 1980

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Olfactory Diagnosis

• Characteristic patient odors accompany many
• diseases and intoxications, and their
• recognition can provide diagnostic clues,
• guide the laboratory evaluation, and affect the
• choice of immediate therapy.
• Hayden, GF Olfactory diagnosis in medicine, Post
  Graduate Medicine,
• 1980

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Inspection Olfactory Diagnosis

• Detection of ingestions or toxins
• Alcohol
• Tobacco
• Toluene
• Cyanide
• Detection of certain infections
• Anaerobic
• Necrotic material

• Diagnosis of certain diseases
• Fruity acetone like Diabetic ketoacidosis
• Urine-like Uremia
• Inborn errors of metabolism

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Inspection Bodily Excretions (Effluvia)

• Video

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Inspection Bodily Excretions (Effluvia)

• Urine, stool, sputum, vomitus, exudates, sweat
• Color, odor, constancy, or smell
• Examples
• Acholic (clay colored) stool of biliary
  obstruction
• Coffee ground emesis of upper gastrointestinal
  hemorrhage
• Rusty sputum of pneumococcal pneumonia
• Melena the black tarry stool from an upper
  gastrointestinal hemorrhage has a distinct odor
• Uremic frost of severe renal failure

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Recording General Observations

• Consider the patient with lung cancer with a
  superimposed pneumonia
• A brief statement at the beginning of the
  physical examination
• A cachextic cyanotic white male sitting upright
  on the edge of the bed in moderate reparatory
  distress
• During the vital signs Respiratory rate 24 and
  labored with use of accessory muscles
• During parts of the physical examination
• HEENT Temporal wasting
• Chest Barrel chested
• Skin Cyanotic and diaphoretic

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Percussion

• Method of physical examination in which the
• surface of the body is struck to emit sounds that
• vary in quality according to the density of the
• underlying tissues.

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Percussion

• Vibration produced by impact of the finger
  against underlying tissue
• Sound waves (resonance) arise from vibrations 4
  to 6 cm deep in the body tissue
• The more dense the material, the quieter the tone

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Techniques of Percussion

• Direct
• Striking finger, hand, or lunar aspect of fist
  directly against the body.
• Indirect
• One finger tip (dominate middle finger) used as a
  hammer (plexar)
• To strike the PIP joint of the middle finger of
  the non-dominate hand as the PIP joint is pressed
  firmly against the area to be percussed
  (pleximeter)

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Percussion Tones

• Tympany Gastric air bubble
• Hyperresonace Emphysemic lung
• Resonance Healthy lung
• Dullness Liver
• Flatness Muscle, thigh

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Uses of Percussion

• Sonorous percussion determine density
• Definitive percussion mapping extent of border
  of an area
• Ex liver
• It is easier to hear the change from resonance to
  dullness so proceed with percussion from areas
  of resonance to areas of dullness
• Detection of areas of tenderness
• Ex flank percussion in pyleonephritis

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Palpation

• Sensitive parts of the hand
• Tactile sense finger pads more sensitive than
  finger tips
• Vibratory sense ulnar aspect of hands, palmer
  metacarpalphalangeal joints
• Position and consistency grasping fingers
• Temperature dorsum of hand

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Qualities Elicited by Palpation

• Texture skin and hair
• Moisture skin
• Temperature skin
• Masses
• Size, shape, consistency, motility, pulsatile
• Precordial cardiac thrust
• Crepitus
• Tenderness
• Vocal Fremitus
•  

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Special Methods of Palpation

• Light palpation up to 1 cm
• Deep palpation up to 4 cm
• Ballottement
• Fluid wave

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Auscultation

• Heart
• Murmurs, clicks, opening snap, gallops,
  pericardial friction rubs and knocks
•  
• Lungs
• Breath sounds, whispers, voice, crackles (rales),
  pleural friction rubs
•  
• Abdomen
• Bowel sounds, bruits
•  

• Neck
• Bruits carotid, thyroid
•  
• Head
• Bruit of AV fistula
•  
• Joints
• Crepitus
•  
• Scrotum
• Bowel sounds from hernia

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Instruments

• Stethoscope
• Ophthalmoscope
• Otoscope
• Near vision chart
• Tuning forks
• Reflex hammer

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Stethoscope

• Conveys a vibrating column of air from the body
  wall to the ears
• Does not amplify, but sounds may be altered
• Excludes extraneous noises

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Stethoscope

• Heart and lung sounds have a frequency between 60
  and 3000 cycles per second
• Hearing range in a young person is 30 to 20,000
  cycles per second, but is dependent upon
  intensity.
• At low intensity range is 70 to 150 cycles per
  second. Therefore some low-pitched sounds may be
  near the limits of auscultation.

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Components of the stethoscope

• Chest piece
• Bell piece
• Transmits all sounds
• Low pitches are transmitted well
• Lightly touch test
• Should have rubber edge
• Diaphragm
• Filters out low pitched sounds
• Isolates high pitched sounds
• Press firmly
• Hold between second and third fingers

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Components of the stethoscope

• Rubber tubing
• Thick walled, stiff, and heavy
• 30 to 40 cm (12 to 18 inches)
• Angled Biaurals
• Point ear pieces towards the nose
• Ear pieces
• Snug
• Comfortable

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Ophthalmoscope

• Lenses and mirrors -20 to 40 diopters
• Light source
• Various apertures
• Small - small pupils
• Red free filter - green beam, optic disc pallor
  and minute vessels changes
• Slit - Anterior eye, elevation of lesions
• Grid - size of fundal lesions

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Otoscope

• Speculum narrows and directs the beam of light
• Glass plate magnifying glass
• Pneumatic attachment - TM mobility
• May be used for nasal examination

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Tuning Forks

• Auditory - 500 to 1000 HZ
• Vibratory - 100 to 400 HZ

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Reflex Hammer

• Tomahawk
• Babinski
• Neurologic hammer

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Other

• Safety pins
• Pen light
• Tape measure
• Ruler
• Q-tips
• Tongue blades
• Near vision chart

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Near Vision Chart

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Vital Signs
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Vital Signs

• Equipment Needed
• A Stethoscope
• A Blood Pressure Cuff
• A Watch Displaying Seconds
• A Thermometer

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Temperature

• Temperature can be measured is several different
  ways
• Oral with a glass, paper, or electronic
  thermometer (normal 98.6F/37C)
• Axillary with a glass or electronic thermometer
  (normal 97.6F/36.3C)
• Rectal or "core" with a glass or electronic
  thermometer (normal 99.6F/37.7C)
• Aural (the ear) with an electronic thermometer
  (normal 99.6F/37.7C)
• Of these, axillary is the least and rectal is the
  most accurate.

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Temperature

• Fever (pyrexia) elevated body temperature
• Hyperpyrexia extreme fever, gt 106F/41.1C
• Hypothermia extremely low temperaturelt 95F/35C

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False measurements

• Patient smoking or drinking hot or cold liquids
• Rapid respiratory rate
• Failure to use thermometer correctly

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Recording

• Temperature in degrees
• Which scale?
• Location,
• (Type of thermometer)
• ex 106F, axillary, (glass)
•  

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Pulse

• Sit or stand facing your patient.
• Grasp the patient's wrist with your free
  (non-watch bearing) hand (patient's right with
  your right or patient's left with your left).
  There is no reason for the patient's arm to be in
  an awkward position, just imagine you're shaking
  hands.
• Compress the radial artery with your index and
  middle fingers.

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Pulse

• Note whether the pulse is regular or irregular
• Regular - evenly spaced beats, may vary slightly
  with respiration
• Regularly Irregular - regular pattern overall
  with "skipped" beats
• Irregularly Irregular - chaotic, no real pattern,
  very difficult to measure rate accurately
• Count the pulse for 15 seconds and multiply by 4.
  
• Count for a full minute if the pulse is
  irregular.
• Record the rate and rhythm.

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Pulse Interpretation

• A normal adult heart rate is between 50 and 100
  beats per minute
• A pulse greater than 100 beats/minute is defined
  to be tachycardia. Pulse less than 60
  beats/minute is defined to be bradycardia.
• Tachycardia and bradycardia are not necessarily
  abnormal. Athletes tend to be bradycardic at rest
  (superior conditioning). Tachycardia is a normal
  response to stress or exercise.

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Respiration

• Best done immediately after taking the patient's
  pulse. Do not announce that you are measuring
  respirations.
• Without letting go of the patients wrist begin to
  observe the patient's breathing. Is it normal or
  labored?

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Respiration

• Count breaths for 15 seconds and multiply this
  number by 4 to yield the breaths per minute.
• In adults, normal resting respiratory rate is
  between 14-20 breaths/minute. Rapid respiration
  is called tachypnea.

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Measurement of Blood Pressure

• Although the arterial blood pressure is measured
  many time a day by doctors all over the world,
  few physicians have devoted much thought to the
  problems and principles involved in measuring
  blood pressure accuratelyFrom the very
  beginning, students must learn to record the
  blood pressure properly. Accurate blood pressure
  recording will then become a habit that will
  remain with the physician for a lifetime."

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Blood Pressure

• Systolic highest BP in the cycle
• Diastolic lowest BP in the cycle
• Pulse pressure difference between systolic and
  diastolic
• Mean arterial pressure (1/3)(SBP DBP) DBP

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Blood Pressure

• Hypertension
• For adults gt140/90
• Graded by severity
• Malignant hypertension acute target organ
  damage
• Hypertension is a risk factor

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Blood Pressure Classification
BP Classification SBP mmHg DBP mmHg
Normal lt120 and lt80
Prehypertension 120139 or 8089
Stage 1 Hypertension 140159 or 9099
Stage 2 Hypertension gt160 or gt100
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Sphygmomanometers

• Types
• Mercury-gravity
• Aneroid
• Automated
•  
• Components
• Pressure manometer
• Inflatable rubber bladder within an inelastic
  covering
• Size is important
• Width - 40 arm circumference
• Length 80 arm circumference
• Most are marked
• Rubber hand bulb and pressure control valve
•  

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THE BLOOD PRESSURE CUFF
CUFF
BLADDER
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Technique of Blood Pressure Measurement

• The patient
• Not smoking, ingesting caffeine, or vigorous
  activity for 30 min prior
• Rest sitting comfortably for 5 10 min
• Room quiet and warm
• Arm rested and free of clothing

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Technique of Blood Pressure Measurement

• Be aware of conditions which may alter BP
• Dialysis fistula
• Lymphedema
• Atherosclerosis
• Anxiety (white coat hypertension)
• Circadian variation
•  

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THE AUSCULTATORY GAP
THE DISAPPERANCE OF THE PHASE 1 KOROTKOFF SOUNDS
IN SYSTOLE WITH REAPPEARANCE ABOVE THE DIASTOLIC
PRESSURE. AVOID BY PALPATING THE DISTAL PULSE
UNTIL IT DISAPPEARS DURING CUFF
INFLATION. MECHANISM UNKNOWN ?ATHEROSCLEROTIC
PLAQUE. 20 OF ELDERLY PATIENTS. MAY LEAD TO
INACCURATE SYSTOLIC AND DIASTOLIC READING.
FALSELY LOW SBP OR FALSELY HIGH DBP.
150/98 200/98 WITH AN AUSCULTATORY GAP BETWEEN
170 - 150
CAVALLINI MC ANN INTERN MED 124887-8831996 BATES
GUIDE TO THE PHYSICAL EXAMINATION 8TH ED.
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Phases of the Korotkoff Sounds

• Phase 1
• Starts with a loud thud
• Recorded at level when 2 beats heard in a row
• Systolic
• There may be an auscultatory gap
• Phase 2
• A blowing or swishing sound

• Phase 3
• Softer thud than phase 1
• Still crisp
• Phase 4
• Muffing
• Softer blowing sounds that disappears
• Phase 5
• Silence
• Diastolic

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Diastolic Blood Pressure

• Special Considerations
•  
• Some controversy if phase 4 or phase 5 is DBP
• Recorded at phase 5, disappearance of sounds
• Usually phase 4 and 5 are close, lt 5 mm Hg
• If more than 10 mm Hg apart
• Record as160/90/68
• In some patients, ex Aortic regurgitation,
  sounds never disappear.
• Record as 150/70/0
•  

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Blood Pressure

• 1. Position the patient's arm so the anticubital
  fold is level with the heart. Support the
  patient's arm with your arm or a bedside table.
• 2. Center the bladder of the cuff over the
  brachial artery approximately 2.5 cm above the
  anticubital fold. Proper cuff size is essential
  to obtain an accurate reading. Be sure the index
  line falls between the size marks when you apply
  the cuff. Position the patient's arm so it is
  slightly flexed at the elbow.

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Blood Pressure

• 3. Palpate the radial pulse and inflate the cuff
  until the pulse disappears. This is a rough
  estimate of the systolic pressure.
• 4. Place the stethoscope over the brachial
  artery.

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Blood Pressure

• 5. Inflate the cuff to 30 mmHg above the
  estimated systolic pressure. Release the pressure
  slowly, no greater than 5 mmHg per second. The
  level at which you consistently hear beats is the
  systolic pressure.

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Blood Pressure

• 6. Continue to lower the pressure until the
  sounds muffle and disappear. This is the
  diastolic pressure. Record the blood pressure as
  systolic over diastolic ("120/70" for example).

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Errors in BP Measurement

• Cuff too small
• Cuff too large
• Arm held below heart
• Loose cuff

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Accurate BP Measurements

• Proper patient conditions - Sitting, relaxed, no
  caffeine or smoking, etc
• Errors in measurement Cuff size, technique
• White coat hypertension
• Pseudohypertension
• Home BP measurements
• 24 hour ambulatory measurements

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CIRCADIAN PATTERNS OF BLOOD PRESSURE
NORMALLY BLOOD PRESSURE FALLS AT NIGHT AND EARLY
MORNING.
NEJM 347778-7792002
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